Pharmaceutical industry and continuing medical education

Sir,

Medicine and its allied branches are growing at an exponential rate, resulting in a deluge of new diagnostic and therapeutic modalities. As clinicians, it may be difficult to keep up with the latest developments. Continuing medical education programs (CMEs) are hence designed to keep medical personnel informed of the latest developments in the pathophysiology and treatment of various conditions. CMEs are also required as a prerequisite for regular renewals of medical license. CMEs are mostly conducted by academic institutions, professional bodies and pharmaceutical companies. As a platform for dissemination of knowledge, CMEs should provide the most up-to-date data supported by an adequate number of well-planned and executed studies in cases of therapeutic topics. Pharmaceutical companies are usually looked at as a source of funds required in organizing a CME program. A large and growing proportion of CME - about 60% in the US - is derived through commercial sponsorship, mainly by pharmaceutical companies. ^[1] Ethical dilemmas arise when a pharmaceutical company sponsors a CME. Several prominent investigations have revealed industry efforts to use educational activities to increase drug sales. ^[2] As a sponsor, a pharmaceutical company looks to maximize the value for its money, and that value is in the form of increased number of prescriptions for its own products. This intent of the company to maximize value of its investment can come at the cost of accuracy of information being disseminated at the CME. Distinctions are blurred between advertising, promotion, information and education.

Few studies have evaluated the effect of content of CME on the prescribing behavior of doctors. In general, physicians rank company-sponsored CME lower than objective sources, such as journal articles, as sources of credible prescribing information. ^[3] Studying the effects of company-funded CME on subsequent prescribing behavior, it was found that in each case there was a greater increase in prescriptions for the drug made by the sponsoring company than for other drugs in the same class. ^[4] Physicians were surveyed before and 6 months after their attendance at three separate CME events conducted to evaluate the change in prescribing habits. Similar findings have been reported by others, which point toward the change in prescribing habits after attending a company-sponsored event. ^[5] In each case, there was a greater increase in prescriptions for the drug made by the sponsoring company than for other drugs in the same class. Not only do pharmaceutical houses spend large sums of money to "educate" physicians at CME events, they also offer large honorarium to leading medical academicians for lectures. Although unintentional, these speakers may lecture in a biased way and feelings of reciprocity and personal relationship may dissuade them from being critical of the sponsoring company′s product. A mere conflict of interest disclosure is not necessarily a guarantee for unbiased information, although, in cases where there is a declaration of conflict of interest, the information is perceived to be more reliable. ^[6] Many CME courses occur at resorts and other such places of leisure. Furthermore, an industry sponsor may pay travel and entertainment expenses for both faculty and postgraduate students. In such a scenario, the authenticity of information being provided is questionable and there are more than subtle attempts to discredit a rival company′s product or make unduly high claims for the sponsoring company′s product.

In academic institutes, guidelines for the conduct of CME are usually present. These guidelines require the course content to be controlled by the institution and generic drug names to be used during the course and alternate therapies to be appropriately identified and addressed. An analysis of the content of CME events in relation to their source of funding showed that, despite these requirements, there was a bias in favor of the sponsoring company′s drug in both courses, although the nature of the bias differed. Two courses on calcium channel blockers funded by different drug companies were analyzed. In the second course, the sponsoring company′s drug was mentioned much more often than either of two competing drugs. For both courses, positive clinical effects were attributed to the sponsoring company′s drug more often than to the other drugs. In the first course, clinical effects attributed to competing drugs were more likely to be negative. ^[4]

In such a scenario, it is important for the medical profession to demarcate what a sponsor company can and cannot expect. It is unlikely that the pharmaceutical industry would contribute substantial resources to CME - approximately $1 billion per year in the US - if there were little return on that investment. ^[7] Sponsorship of an educational program differs from setting up an informational booth at a symposium. A clinician might pay no attention to a leaflet handed to him or an imprinted notepad at a symposium, but he is much more likely to respond to information being given out at an educational event. The sanctity of an educational exercise has to be maintained for it influences on future prescription trends and treatment modalities. Voluntary regulation by pharmaceutical manufacturers has not been very effective, and it is up to the professional bodies in the medical field to come up with policy guidelines for industry academia interactions, with special clarity in matters relating to money. Such steps have been taken and a start has been made. ^[8] It is up to the physicians to stay on their guard and desist from attempts at being coerced - consciously or subconsciously - and use only the best available evidence when prescribing. In a developing country like India, this is of special significance as moving to newer and costlier drugs when effective and cheap alternatives are available is a bad decision and adds to the cost of therapy.